Early Neutrophilia Is Associated With Volume

of Ischemic Tissue in Acute Stroke

Brian H. Buck, MD; David S. Liebeskind, MD; Jeffrey L. Saver, MD; Oh Young Bang, MD, PhD;
Susan W. Yun, BSc; Sidney Starkman, MD; Latisha K. Ali, MD; Doojin Kim, MD;
J. Pablo Villablanca, MD; Noriko Salamon, MD; Tannaz Razinia, BSc; Bruce Ovbiagele, MD

Background and PurposeFew data exist on the relationship between differential subpopulations of peripheral leukocytes
and early cerebral infarct size in ischemic stroke. Using diffusion-weighted MR imaging (DWI), we assessed the
relationship of early total and differential peripheral leukocyte counts and volume of ischemic tissue in acute stroke.
MethodsAll included patents had laboratory investigations and neuroimaging collected within 24 hours of stroke onset.
Total peripheral leukocyte counts and differential counts were analyzed individually and by quartiles. DWI lesions were
outlined using a semiautomated threshold technique. The relationship between leukocyte quartiles and DWI infarct
volumes was examined using multivariate quartile regression.
Results173 patients met study inclusion criteria. Median age was 73 years. Total leukocyte counts and DWI volumes
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showed a strong correlation (Spearman rho0.371, P000.1). Median DWI volumes (mL) for successive neutrophil
quartiles were: 1.3, 1.3, 3.2, and 20.4 (P for trend 0.001). Median DWI volumes (mL) for successive lymphocyte
quartiles were: 3.2, 8.1, 1.3, and 1.5 (P0.004). After multivariate analysis, larger DWI volume remained strongly
associated with higher total leukocyte and neutrophil counts (both probability values 0.001), but not with lymphocyte
count (P0.4971). Compared with the lowest quartiles, DWI volumes were 8.7 mL and 12.9 mL larger in the highest
quartiles of leukocyte and neutrophil counts, respectively.
ConclusionsHigher peripheral leukocyte and neutrophil counts, but not lymphocyte counts, are associated with larger
infarct volumes in acute ischemic stroke. Attenuating neutrophilic response early after ischemic stroke may be a viable
therapeutic strategy and warrants further study. (Stroke. 2008;39:355-360.)
Key Words: diffusion-weighted imaging inflammation ischemic leukocytosis
magnetic resonance imaging stroke

E xperimental models of stroke have shown that within

minutes of the onset of focal ischemia there is activation
of microglia followed by increased trafficking of leukocytes
into the ischemic territory.1 In stroke patients, a rise in total
peripheral leukocyte count in the first 72 hours after stroke
onset is associated with larger final infarct volumes on
computerized tomography (CT) and magnetic resonance im-
aging (MRI)2 and increased stroke severity.3,4 Studies have
also shown a distinct temporal profile in the recruitment of
inflammatory cells to ischemic brain (see review).5 Neutro-
phils are the earliest leukocyte subtype to show substantial
upregulation in gene expression6 and to infiltrate areas of
brain ischemia.7 Early neutrophil activation has been impli-
cated in the potentiation of postischemic brain injury,8 and
furthermore animal stroke models have suggested that deplet-
ing circulating neutrophils either before or at the onset of
stroke reduces the size of infarction.9
In stroke patients, little information is available regarding
the relationship of circulating leukocyte subtypes and the
extent of ischemic brain injury, before the presence of
substantial established infarction. The objective of this study
was to examine total and differential leukocyte counts in the
first 24 hours after stroke symptom onset. We hypothesized
that a rise in leukocyte counts and specifically the neutrophil
fraction would be associated with the volume of bioenergeti-
cally compromised brain tissue as measured with diffusion-
weighted (DWI) MRI.
Methods
Study Population
This is a secondary analysis of a prospectively maintained database
of consecutive ischemic stroke patients admitted to a university
stroke program. Criteria for inclusion in this study were: age 18

Received April 5, 2007; final revision received June 19, 2007; accepted July 4, 2007.
From the Division of Neurology (B.H.B.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; the Stroke Center and Department of
Neurology (B.H.B., D.S.L., J.L.S., O.Y.B., S.W.Y., S.S., L.K.A., D.K., T.R., B.O.), University of California, Los Angeles; the Department of Neurology
(O.Y.B.), Samsung Medical Center, Sungkyunkwan University, South Korea; the Stroke Center and Department of Radiology (J.P.V., N.S.), University
of California, Los Angeles; and the Department of Emergency Medicine (S.S.), University of California, Los Angeles.
Correspondence to Brian H. Buck MD, FRCPC, Division of Neurology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, room A421,
Toronto, Ontario, Canada M4N3M5. E-mail brianhbuck@gmail.com
2008 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.107.490128

355
 356 Stroke February 2008
years, diagnosis of acute ischemic stroke, multimodal MRI per-
formed within 24 hours of last known well time, peripheral leukocyte
count and differential performed on admission blood work, and
admission during an 18-month period beginning January 1, 2004.
The study was approved by the hospital Institutional Review Board.
MRI Methods and Image Analysis
Patients were imaged before receiving any reperfusion therapy with
a 1.5-T Siemens Vision scanner (Siemens Medical System) using a
protocol detailed previously,10 which included DWI, perfusion
weighted imaging, gradient-recalled echo examination, and fluid
attenuated inversion recovery imaging (FLAIR). DWI was per-
formed with 2 levels of diffusion sensitization (b0 and 1000
s/mm2) with the following parameters: 5 to 7 mm slice thickness, no
gap, and 17 to 20 slices. DWI lesion volumes were measured with
MIPAV software (Medical Image Processing, Analysis and Visual-
ization, version 3.0, National Institutes of Health, Bethesda, Md).
Raters outlined regions of acute diffusion abnormality on the
b1000 image, consulting apparent diffusion coefficient and FLAIR
sequences to distinguish acute from nonacute diffusion change.
Acute diffusion lesions were defined on a slice-by-slice basis using
a semiautomatic threshold approach by a rater blinded (BHB) to all
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clinical information. Lesion volumes were calculated by multiplying
slice thickness by the total lesion area. To assess interrater reliability
lesions volumes were measured by a second rater (OYB) on a
randomly selected subset of 19 patients.
Statistical Methods
Admission total leukocyte, lymphocyte, and neutrophil counts were
collapsed into quartiles. Patient characteristics and other relevant
admission variables were compared across quartiles to look for any
baseline differences. Nonnormally distributed continuous variables
were compared across quartiles according to median values and
tested for statistical significance using the KruskalWallis rank
sum test. Differences in categorically variables were compared
using a 2 test. Where multiple post-hoc tests were performed as
with the comparisons of stroke subtypes between leukocyte, lym-
phocyte, and neutrophil quartiles a Bonferroni method was used to
maintain an of 0.05. Interrater reliability for DWI measurements
was assessed by calculation of the intraclass correlation coefficient
with greater than 0.80 set as the threshold for good agreement.
The distribution of DWI volumes was assessed for deviation from
normality and was skewed to the left, with more small than large
lesion volume patients in the study population. Because of the
non-Gaussian distribution for DWI lesion volumes, median (or
quartile) regression was selected to examine the relationship between
leukocyte counts, DWI volumes, and clinical outcomes, because it is
less sensitive than parametric regression methods to extreme
outliers.11
Median regression was used to examine the association of admis-
sion leukocyte, lymphocyte, and neutrophil counts with DWI vol-
ume. The regression analysis was performed in 2 stages. First the
bivariate relationship between WBC quartiles and imaging was
examined. Next, multivariate median was used to correct for poten-
tial confounding variables. Covariates were selected based on prior
literature,12,13 and included the following categorical variables:
history of atrial fibrillation, previous stroke, history of statin use,
diabetes, and the stroke subtype; and continuous variables: age,
blood glucose, temperature, time to MRI scan, and systolic blood
pressure. Statistical analysis was performed using STATA version
9.1 software (Stata Corporation).
Results
One hundred seventy-three of 322 patients met the study
criteria. Reasons for exclusion were: presented outside of 24
hours, 85; no leukocyte count or MRI was available, 64. Of
the 173 patients, 163 patients had a differential performed on
the total leukocyte count. Among the 173 patients, median
age was 73 (range 24 to 100) and 101 (50.5%) were women.
Racial distribution was 66% white, 12% black, 13% Asian,
and 0.6% other. Ethnic distribution was 9% Hispanic and
91% not Hispanic. The median NIHSS on presentation was 4
(interquartile [IQR] range 2 to 12; full range 0 to 38) and the
meanSD time between last known well time and the MRI
scan was 10.77.9 hours (range 0.7 to 24). Stroke subtypes
classified using the modified TOAST criteria14 were: 41%
cardioembolic, 17.4% large vessel atherothromboembolic,
25.4% small vessel occlusion, 13.3% stroke of undetermined
etiology, and 5.8% other etiology. On discharge, 94 (54.3%)
had poor outcome defined as discharge Rankin 2.
Leukocyte count was measured at a meanSD of 9.67.3
hours after stroke onset. The meanSD total peripheral
leukocyte, neutrophil, and lymphocyte counts were:
8.733.36, 6.173.15, and 1.830.83109cells/L, respec-
tively. The meanSD time between the MRI and leukocyte
collection was 1.15.3 hours.
Table 1 shows population demographic information, risk
factors, and admission clinical characteristics by quartile of
leukocyte count. Patients with high leukocyte counts were
more often Hispanic and tended to have higher baseline
stroke severity NIH Stroke Scale scores. There were no other
differences in the premorbid risk factor profile, use of
antithrombotic and statin medication, admission blood pres-
sure, and temperature across leukocyte quartiles. Addition-
ally, the time between stroke onset and collection of MRI and
leukocyte bloodwork did not differ between quartiles.
Across all patients, the median DWI lesion volume was 2.9
mL (IQR 0.52 to 19.75 mL, full range 0 to 279.0 mL), and
there was good interrater reliability in the measurement of
DWI lesion volumes (interclass correlation coeffi-
cient0.985). The distribution of DWI volumes was posi-
tively skewed reflecting a larger proportion of patients with
smaller lesion volumes (skewness3.4, kurtosis13.2). Me-
dian DWI volumes (IQR) for small vessel, cardioembolic,
large vessel, other, and unknown TOAST subgroups were,
respectively: 0.38 mL (0.26 to 0.97), 7.24 mL (1.89 to 35.17),
5.12 mL (1.19 to 12.51), 15.86 mL (1.22 to 63.24), and 10.84
mL (0.62 to 51.37).
Association Between Total Leukocyte Quartiles
and Stroke Subtype
The distribution of TOAST stroke subtypes differed across
leukocyte quartiles and neutrophil quartiles (P0.001) but
not lymphocyte quartiles. The percentage of patients with
small vessel, cardioembolic, large vessel, other, and unknown
classifications within each leukocyte and neutrophil quartile
are shown in Figure 1. Pairwise comparisons of the propor-
tions of patients with a given stroke subtype were performed
across leukocyte and neutrophil quartiles. In the lowest
leukocyte quartile, 50% of strokes were classified as small
vessel occlusion, which was a greater proportion than in the
3 higher leukocyte quartiles (19%, 23% and 9%, respectively;
P0.05). The proportions of cardioembolic and large vessel
strokes mechanisms did not differ between leukocyte quar-
tiles. Across neutrophil quartiles, the proportion of small
vessel occlusion was larger in the lowest compared with the
highest quartile (43% versus 8%, P0.05). None of the other
differences were significant.
 Buck et al Neutrophilia and DWI Volume in Acute Stroke 357

Table 1. Baseline Demographic and Clinical Characteristics of Blood Leukocyte Quartiles

Blood Leukocyte Quartiles
st nd
1 2 3rd 4th
6.52109 cells/L 6.527.90109 cells/L 7.9110.19109 cells/L 10.20109 cells/L
Characteristic (n44) (n43) (n43) (n43) P Value
Demographics, n (%)
Median age, y (range) 74 (5984) 72 (6481) 73 (6083) 72 (5980) 0.8171
Male sex 21 (48%) 20 (47%) 22 (51%) 20 (47%) 0.9692
White race 28 (64%) 33 (77%) 29 (67%) 24 (56%) 0.2268
Hispanic 3 (7%) 0 (0%) 8 (19%) 4 (9%) 0.0218
History, n (%)
Hypertension 34 (77%) 31 (72%) 30 (70%) 31 (72%) 0.8811
Diabetes 9 (20%) 11 (26%) 8 (19%) 9 (21%) 0.8788
Hyperlipidemia 14 (32%) 16 (37%) 13 (30%) 15 (35%) 0.9046
CAD 10 (23%) 8 (19%) 7 (16%) 6 (14%) 0.7425
Atrial fibrillation 6 (14%) 9 (21%) 8 (19%) 6 (14%) 0.7551
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Current smoking 2 (5%) 7 (16%) 6 (14%) 5 (12%) 0.3483

Prior stroke/TIA 11 (25%) 14 (33%) 8 (19%) 9 (21%) 0.4521
Prestroke medications, n (%)
Antithrombotic 22 (50%) 24 (56%) 22 (51%) 16 (37%) 0.3509
Statin 9 (20%) 14 (33%) 7 (16%) 11 (26%) 0.3187
Admission, median (IQR)
Temperature, C 36.5 (0.7) 36.5 (0.8) 36.8 (0.8) 36.6 (0.5) 0.120
Systolic BP, mm Hg 153 (49) 153 (43) 146 (38) 138 (46) 0.1090
Blood glucose, mg/dl 113 (27) 111 (29) 115 (31) 118 (45) 0.3436
Admission NIHSSS 3 (3) 4 (11) 5 (15) 9 (16) 0.0582
Time to MRI, hours 6.6 (13.2) 8.8 (12.8) 9.7 (18.8) 6.7 (14.2) 0.6124
Stroke subtype
Cardioembolic 15 (34%) 17 (40%) 20 (47%) 19 (44%) 0.0001*
Large vessel atherosclerosis 3 (7%) 12 (28%) 9 (21%) 6 (14%)
Small vessel disease 22 (50%) 8 (19%) 10 (23%) 4 (9%)
Other 0 (0%) 2 (5%) 3 (7%) 5 (12%)
Unknown 4 (9%) 4 (9%) 1 (2%) 9 (21%)
CAD indicates coronary artery disease; TIA, transient ischemic attack; BP, blood pressure; NIHSS, National Institutes of Health Scale score; DWI,
diffusion weighted imaging.
For counts the percentages are shown in parenthesis and interquartile ranges are reported for all reported medians.
P value for difference between quartiles of total leukocyte count, using chi-square for percentages and rank sum tests for medians.
*Other and unknown stroke subtypes were collapsed for the statistical test.

Association of Total Leukocyte, Lymphocyte, and
Neutrophil Quartiles With DWI Lesion Volume
The median (IQR) DWI lesion volumes by quartile of total
leukocyte count, neutrophil count, and lymphocyte count are
shown in Table 2, including both univariate and adjusted
multivariate analyses. DWI volume was positively correlated
with total leukocytes (Spearman rho0.371, P0.001) and
neutrophils (Spearman rho0.415, P0.001) but not lym-
phocytes. On bivariate median regression analysis, higher
leukocyte quartiles were significantly associated with larger
DWI lesion volumes (Table 2). Patients in the highest
leukocyte quartile had significantly larger median lesion
volumes than the lower 3 quartiles. None of the 3 lower
quartiles differed significantly from each other.
Both neutrophil and lymphocyte counts were significantly
associated with DWI lesion volume. The results for the
neutrophil count were similar to that of the total leukocyte
count. The volume in the highest quartile was significantly
larger than the lower 3 quartiles. DWI volumes in the lower
3 neutrophil quartiles did not differ significantly from each
other. The pattern for the lymphocyte count was different and
showed the DWI lesion volume in the second quartile to be
significantly larger than the other 3 quartiles.
The multivariate estimated effect sizes of total leukocyte
and neutrophil quartiles on DWI lesion volumes showed a
similar pattern to the bivariate analysis. Elevated leukocyte
and neutrophil count remained positively associated with
DWI lesion volumes. Figure 2 shows the multivariate ad-
justed median DWI volumes, IQR, and 95% CI for each of
the neutrophil quartiles. Pairwise comparison showed that the
difference in DWI volumes in the highest neutrophil quartile
was significantly larger than the lower 3 quartiles (P0.001).
 358 Stroke February 2008

Figure 2. Box plot showing multivariate adjusted median DWI

volumes (solid bar), interquartile range (bar width), and mini-
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mum/maximum values (whiskers) across neutrophil quartiles.

Figure 1. Classification of stroke mechanism within leukocyte
and neutrophil quartiles.
The difference in DWI volumes across the other 3 neutrophil
quartiles was not significant. After adjusting for covariates,
the association between lymphocyte counts and DWI volume
was no longer significant.
Discussion
We found that in ischemic stroke patients evaluated within 24
hours of symptom onset, elevated peripheral total leukocyte
and neutrophil counts were associated with larger volumes of
ischemic tissue as measured by DWI MRI. The volumes of
DWI abnormality in patients in the highest total leukocyte
and neutrophil quartiles were substantially larger than in the
lowest quartile. This effect partially reflected the larger
proportion of patients with small vessel stroke noted in the
lowest total leukocyte and neutrophil quartiles; however,
even after adjusting for stroke mechanism and other poten-
tially confounding variables there remained a robust finding

Table 2. Infarct Volumes According to Quartiles of Total Leukocyte, Lymphocyte, and

Neutrophile Count (109 cells/L) for Univariate and Multivariate Models
Univariate DWI Volume (mL) Multivariate* DWI Volume (mL)
Median (IQR) (95% CI)
Total leukocyte
Quartile 1 6.5 0.9 (0.3,2.0) ref
Quartile 2 6.57.9 2.9 (0.5,10.4) 0.9 (2.9,4.8)
Quartile 3 7.9110.2 3.7 (0.7, 21.1) 1.2 (2.5,4.9)
Quartile 4 10.2 15.1 (1.4,53.6) 8.6 (4.6,12.5)
P value for trend 0.0001 0.0001
Lymphocyte
Quartile 1 4.1 3.2 (0.8,25.4) ref
Quartile 2 4.15.4 8.1 (2.2,21.3) 0.4 (2.5,3.3)
Quartile 3 5.417.5 1.3 (0.4,6.0) 2.5 (5.3,0.3)
Quartile 4 7.5 1.5 (0.5,14.0) 1.5 (4.3,1.4)
P value for trend 0.004 0.2064
Neutrophil
Quartile 1 1.2 1.3 (0.4,4.9) ref
Quartile 2 1.211.7 1.3 (0.4,5.0) 1.12 (4.0,1.74)
Quartile 3 1.712.3 3.2 (0.5,20.6) 0.4 (3.2,2.4)
Quartile 4 2.3 20.4 (8.0,53.6) 13.0 (9.8,16.1)
P value for trend 0.0001 0.0001
Two-sided P value based on univariate and multivariate quartile regression.
*Effect estimates adjusted for diabetes, atrial fibrillation, previous stroke, statin pretreatment, antithrombotic
pretreatment, stroke mechanism, age, blood glucose, temperature, systolic blood pressure, and time to MRI.
IQR indicates interquartile range; DWI, diffusion-weighted imaging; ref, referent quartile.
 Buck et al
of increased DWI volume in the highest total leukocyte and
neutrophil quartiles. Analysis of differential subpopulations
of peripheral leukocytes indicated that the total leukocyte
effect was largely attributable to the positive association
between the neutrophil fraction and DWI volume because we
did not find any independent relationship between DWI
volumes and lymphocyte counts. This effect did not appear to
be present across the full range of neutrophil counts, but
rather there was a threshold between the third and fourth
quartiles above which elevation in neutrophil counts was
associated with significantly larger infarct volumes.
These results are consistent with previous studies that have
reported a relationship between lesion size and elevated
markers of systemic inflammatory response including WBC,
body temperature, C-reactive protein, and additional inflam-
matory biomarkers.1,2,15,16 Studies that have correlated the
inflammatory cell response with infarct volumes have almost
exclusively used CT or T2-weighted MRI.2,17 There have
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been studies that have looked at inflammatory markers in
relation to DWI lesion volumes in small numbers of pa-
tients.16,18 This study is distinct in that DWI MRI was used to
determine volumes of ischemic tissue early after onset. DWI
MRI demarcates brain tissue in which there has been a failure
of cellular energy-dependent processes attributable to cere-
bral hypoperfusion and predicts final infarct volume well,
albeit imperfectly.19,20 Our finding that total leukocyte and
neutrophil counts are associated with DWI lesion volumes
suggests this inflammatory response occurs early, before the
development of large volumes of infarcted or necrotic tissue.
Several mechanisms may contribute to the association
between leukocyte count and DWI lesion volume. Athero-
sclerosis is increasingly being viewed as a chronic inflamma-
tory disease,21 and one possibility is that an elevation in
leukocyte count predates the stroke onset and reflects the
burden of atherosclerotic disease. Leukocytosis has been
associated with degree of atherosclerosis,22,23 is a risk factor
for cardiovascular events and stroke,24,25 is related to stroke
subtype,24 and consequently may affect DWI lesion volumes.
Furthermore, there is evidence leukocytosis may be associ-
ated with plaque destabilization and the induction of acute
thrombotic events.26,27 This study provides some support for
an interplay of these mechanisms. We found a greater
proportion of patients with small vessel occlusion in the
lowest (versus highest) total leukocyte quartiles, whereas the
upper 3 quartiles trended toward larger proportions of pa-
tients with cardioembolic and large vessel atherosclerotic
mechanisms. This finding accords with a population-based
study that found that stroke-free individuals with the highest
quartile of leukocyte count have an overall increased risk of
stroke compared with the lowest quartile, and the risk is more
pronounced for atherosclerotic and cardioembolic subtypes.24
However, because monocyte-macrophages and lymphocytes
are the major immune cells implicated in atherosclerotic
lesions,28 our finding that elevated neutrophils were corre-
lated with larger DWI volumes cannot fully be explained by
an association with premorbid atherosclerotic burden.
Another possibility is that increased admission leukocyte
counts reflect the presence of premorbid infection. After
infection the incidence of stroke exceeds the general age-
Neutrophilia and DWI Volume in Acute Stroke 359
matched stroke incidence by 2- to 3-fold, possibly as a result
of increased platelet leukocyte aggregation and platelet acti-
vation.29 We attempted to control for clinically-manifest
concurrent infection by adjusting for body temperature in the
multivariate analyses, and this did not affect the relationship
noted between neutrophil counts and DWI lesion volume.
Elevation in leukocyte counts and specifically the neutro-
phil population may have occurred after the onset of stroke,
with greater inflammatory response contributing to greater
ischemic brain injury.30 The present finding that only the
neutrophil quartile and not lymphocytes predicted DWI
lesion volume is in keeping with the known temporal profile
of inflammatory cell involvement in the hyperacute phases of
stroke. Prior studies have shown that neutrophils are among
the earliest inflammatory cell type to show substantial up-
regulation in gene expression6 and to infiltrate the ischemic
brain.7 Recruitment of neutrophils can be detected as early as
5 hours after stroke onset and peaks at 24 hours.1
It must also be acknowledged that the association of
neutrophilia and lesion volume we detected may be an
epiphenomenon. Large infarcts may provoke a greater stress
and inflammatory response as a secondary reaction to the
initial brain injury.
This study has some limitations. This is a cross-sectional
study, and the cause and effect relationship between total
leukocyte and neutrophil quartiles and DWI lesion volume
cannot be determined. Serial measures of leukocytes and
lesion volume during the first hours after stroke onset could
potentially better illuminate the potential role of inflamma-
tory cells in the propagation of ischemic injury, but are
logistically challenging to accomplish. To control for premor-
bid infection we used body temperature. Systemic infection
may occur without elevations in body temperature, and future
studies should include additional biomarkers of inflammation
such as high sensitivity CRP. Initial DWI lesion volume was
analyzed, not final T2-weighted lesion volume, as late T2
studies were not obtained routinely in these patients. How-
ever, multiple studies have demonstrated that early DWI lesion
volumes correlate well with final T2 lesion volumes.31,32
In conclusion, in acute ischemic stroke early elevation of
total leukocyte count and neutrophil count is associated with
larger volume of early ischemic tissue. Part of this effect is
attributable to an association of small vessel stroke mecha-
nism with low leukocyte count, but even after adjustment for
this and other factors, the association of inflammatory cells
and early lesion volume remains robust. To date, clinical
trials of agents that modulate inflammation in acute stroke
have been disappointing.33,34 Determining whether suppress-
ing the response of neutrophils can help reduce the propaga-
tion of ischemic damage should continue to be an important
goal of future investigations.
Sources of Funding
This work was supported in part by Heart and Stroke Foundation of
Canada fellowship award (to B.H.B.) and NIH/NINDS P50
NS044378 (to J.L.S.).
Disclosures
None.
 360 Stroke February 2008
References
1. Nilupul Perera M, Ma HK, Arakawa S, Howells DW, Markus R, Rowe CC,
Donnan GA. Inflammation following stroke. J Clin Neurosci. 2006;13:18.
2. Audebert HJ, Rott MM, Eck T, Haberl RL. Systemic inflammatory
response depends on initial stroke severity but is attenuated by successful
thrombolysis. Stroke. 2004;35:2128 2133.
3. Christensen H, Boysen G. C-reactive protein and white blood cell count
increases in the first 24 hours after acute stroke. Cerebrovasc Dis. 2004;
18:214 219.
4. Pozzilli C, Lenzi GL, Argentino C, Bozzao L, Rasura M, Giubilei F,
Fieschi C. Peripheral white blood cell count in cerebral ischemic
infarction. Acta Neurol Scand. 1985;71:396 400.
5. Wang Q, Tang XN, Yenari MA. The inflammatory response in stroke.
J Neuroimmunol. 2007;184:53 68.
6. Tang Y, Xu H, Du X, Lit L, Walker W, Lu A, Ran R, Gregg JP, Reilly
M, Pancioli A, Khoury JC, Sauerbeck LR, Carrozzella JA, Spilker J,
Clark J, Wagner KR, Jauch EC, Chang DJ, Verro P, Broderick JP, Sharp
FR. Gene expression in blood changes rapidly in neutrophils and
monocytes after ischemic stroke in humans: A microarray study. J Cereb
Blood Flow Metab. 2006;26:1089 1102.
7. Yamagami S, Tamura M, Hayashi M, Endo N, Tanabe H, Katsuura Y,
Komoriya K. Differential production of mcp-1 and cytokine-induced
neutrophil chemoattractant in the ischemic brain after transient focal
Downloaded from http://stroke.ahajournals.org/ by guest on April 28, 2017
ischemia in rats. J Leukoc Biol. 1999;65:744 749.
8. Akopov SE, Simonian NA, Grigorian GS. Dynamics of poly-
morphonuclear leukocyte accumulation in acute cerebral infarction and
their correlation with brain tissue damage. Stroke. 1996;27:1739 1743.
9. Jiang N, Moyle M, Soule HR, Rote WE, Chopp M. Neutrophil inhibitory
factor is neuroprotective after focal ischemia in rats. Ann Neurol. 1995;
38:935942.
10. Liebeskind, Kidwell. Advanced MR imaging of acute stroke: The Uni-
versity of California at Los Angeles endovascular therapy experience.
Neuroimaging Clin N Am. 2005;15:455 466.
11. Koenker R, Hallock K. Quantile regression. J Econ Perspect. 2001;15:
143156.
12. Frankel MR, Morgenstern LB, Kwiatkowski T, Lu M, Tilley BC,
Broderick JP, Libman R, Levine SR, Brott T. Predicting prognosis
after stroke: A placebo group analysis from the National Institute of
Neurological Disorders and Stroke rt-PA Stroke trial. Neurology.
2000;55:952959.
13. Shook SJ, Gupta R, Vora NA, Tievsky AL, Katzan I, Krieger DW. Statin
use is independently associated with smaller infarct volume in nonlacunar
MCA territory stroke. J Neuroimaging. 2006;16:341346.
14. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL,
Marsh EED. Classification of subtype of acute ischemic stroke. Defi-
nitions for use in a multicenter clinical trial. Toast. Trial of org 10172 in
acute stroke treatment. Stroke. 1993;24:35 41.
15. Smith CJ, Emsley HC, Gavin CM, Georgiou RF, Vail A, Barberan EM,
del Zoppo GJ, Hallenbeck JM, Rothwell NJ, Hopkins SJ, Tyrrell PJ. Peak
plasma interleukin-6 and other peripheral markers of inflammation in the
first week of ischaemic stroke correlate with brain infarct volume, stroke
severity and long-term outcome. BMC Neurol. 2004;4:2.
16. Winbeck K, Poppert H, Etgen T, Conrad B, Sander D. Prognostic rel-
evance of early serial C-reactive protein measurements after first ische-
mic stroke. Stroke. 2002;33:2459 2464.
17. Suzuki S, Kelley RE, Reyes-Iglesias Y, Alfonso VM, Dietrich WD.
Cerebrospinal fluid and peripheral white blood cell response to acute
cerebral ischemia. South Med J. 1995;88:819 824.
18. Montaner J, Rovira A, Molina CA, Arenillas JF, Ribo M, Chacon P,
Monasterio J, Alvarez-Sabin J. Plasmatic level of neuroinflammatory
markers predict the extent of diffusion-weighted image lesions in
hyperacute stroke. J Cereb Blood Flow Metab. 2003;23:14031407.
19. Kidwell CS, Alger JR, Saver JL. Beyond mismatch: Evolving paradigms
in imaging the ischemic penumbra with multimodal magnetic resonance
imaging. Stroke. 2003;34:2729 2735.
20. Kidwell CS, Saver JL, Starkman S, Duckwiler G, Jahan R, Vespa P,
Villablanca JP, Liebeskind DS, Gobin YP, Vinuela F, Alger JR. Late
secondary ischemic injury in patients receiving intraarterial thrombolysis.
Ann Neurol. 2002;52:698 703.
21. Ross R. Atherosclerosisan inflammatory disease. N Engl J Med. 1999;
340:115126.
22. Elkind MS, Cheng J, Boden-Albala B, Paik MC, Sacco RL. Elevated
white blood cell count and carotid plaque thickness: The northern man-
hattan stroke study. Stroke. 2001;32:842 849.
23. Loimaala A, Rontu R, Vuori I, Mercuri M, Lehtimaki T, Nenonen A,
Bond MG. Blood leukocyte count is a risk factor for intima-media
thickening and subclinical carotid atherosclerosis in middle-aged men.
Atherosclerosis. 2006;188:363369.
24. Elkind MSV, Sciacca RR, Boden-Albala B, Rundek T, Paik MC, Sacco
RL. Relative elevation in baseline leukocyte count predicts first cerebral
infarction. Neurology. 2005;64:21212125.
25. Madjid M, Awan I, Willerson JT, Casscells SW. Leukocyte count and
coronary heart disease: Implications for risk assessment. J Am Coll
Cardiol. 2004;44:19451956.
26. Elkind MS. Inflammation, atherosclerosis, and stroke. Neurologist. 2006;
12:140 148.
27. Stoll G, Bendszus M. Inflammation and atherosclerosis: Novel insights
into plaque formation and destabilization. Stroke. 2006;37:19231932.
28. Libby P, Ridker PM, Maseri A. Inflammation and atherosclerosis.
Circulation. 2002;105:11351143.
29. Zeller JA, Lenz A, Eschenfelder CC, Zunker P, Deuschl G. Platelet-
leukocyte interaction and platelet activation in acute stroke with and
without preceding infection. Arterioscler Thromb Vasc Biol. 2005;25:
1519 1523.
30. Becker KJ. Targeting the central nervous system inflammatory response
in ischemic stroke. Curr Opin Neurol. 2001;14:349 353.
31. Schaefer PW, Hunter GJ, He J, Hamberg LM, Sorensen AG, Schwamm
LH, Koroshetz WJ, Gonzalez RG. Predicting cerebral ischemic infarct
volume with diffusion and perfusion MR imaging. Am J Neuroradiol.
2002;23:17851794.
32. Albers GW. Diffusion-weighted MRI for evaluation of acute stroke.
Neurology. 1998;51:S47 49.
33. Krams M, Lees KR, Hacke W, Grieve AP, Orgogozo J-M, Ford GA.
Acute stroke therapy by inhibition of neutrophils (ASTIN): An adaptive
dose-response study of UK-279,276 in acute ischemic stroke. Stroke.
2003;34:25432548.
34. Ovbiagele B, Kidwell CS, Starkman S, Saver JL. Neuroprotective agents
for the treatment of acute ischemic stroke. Curr Neurol Neurosci Rep.
2003;3:9 20.
 Early Neutrophilia Is Associated With Volume of Ischemic Tissue in Acute Stroke
Brian H. Buck, David S. Liebeskind, Jeffrey L. Saver, Oh Young Bang, Susan W. Yun, Sidney
Starkman, Latisha K. Ali, Doojin Kim, J. Pablo Villablanca, Noriko Salamon, Tannaz Razinia
and Bruce Ovbiagele
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Stroke. 2008;39:355-360; originally published online December 27, 2007;

doi: 10.1161/STROKEAHA.107.490128
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